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October 2005, Vol. 15, Iss. 4
Table of Contents
A Time to Change • CBP® Annual Convention News • CBP® Performs Groundbreaking Car Crash Research • CCE Cited for Accreditation Violation • Dr Colloca Becomes a Reviewer for Spine and the European Spine Journal • ICA's Involvement in Hurricane Relief Efforts • JMPT Publications: Impulse™ Fairs Best Among Chiropractic Adjusting Instruments • Its Paul's Opinion • Letters to the Editor • Life University Opens Its Arms and Hearts to Katrina Victims • Micro-Reports Don't Work • PosturePrint™ Can Determine Axial Rotations • Quackbuster vs. Dr Ted Koren • The Chiropractic Genome • The Start of Something Big • The Unspoken • Updates on Aspertame
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The Start of Something Big: The Initial Patient History and Exam
by Scott J. Heun, D.C.
Dr. Heun practiced chiropractic very successfully for over twenty years. As a second generation chiropractor he has a unique perspective on the profession. At various times he has owned and operated single and multi-doctor offices, managed multiple office locations, as well as a physical therapy and rehabilitation center. Dr. Heun successfully implemented an intern program in the last 8 years of practice and was a preceptor for Palmer College of Chiropractic-West. Dr. Heun is a Certified Chiropractic Sports Physician (CCSP), taught the CBP® II elective at Life-West and is a CBP® Certified Fellow and CBP® Instructor. Dr. Heun retired from practice in 2004 and is now a full time practice consultant with Total Practice Management International, LLC.
Much has been written regarding the importance of doctor patient communication.1 A review of the literature on the subject supports the conclusion that a direct correlation exists between the caliber of interpersonal communication of the doctor directed to, and received by the patient, and the successful outcome of the therapy of choice employed. The implication of this information for chiropractors is critical. In light of the fact that the reliability of most orthopedic testing has questionable validity,2 the history of the present illness, and exploration of the past history, coupled with the impact of the injury or condition on the patients activities of daily living, may very well produce a more dependable assessment of the patients problem than a physical examination. Due to the fact that the inter-examiner and intra-examiner reliability of radiographic, visual or photographic postural investigation is very high,3 the scientifically based chiropractor may inadvertently neglect the importance of establishing a solid connection with a patient via verbal and non-verbal communication. If committed, this oversight will likely have a serious detrimental effect upon the outcome of CBP® patient care protocol. Therefore, the most critical part of the initial patient history and examination is the bond created between doctor and patient. This bond is the result of verbal and non-verbal communication initiated by the doctor. The success or failure of the doctor patient relationship, and ultimately, the care provided to the patient, is primarily dependent upon the creation of this unique human connection.
The nature of CBP® patient care, beyond the resolution of symptoms, requires the chiropractor employ not only manipulation and drop table adjusting, but also ergonomic education, in-office traction, and Mirror- Image® exercise to achieve optimal structural improvement.4 Therefore, the patient must commit to spending a significant amount of time in the doctor’s office, a minimum of three, and preferably four days each week. This time dependent component of patient care necessitates the doctor establish trust, and enjoin the confidence of the patient, in order to maximize patient compliance with the CBP® protocol. Furthermore, the doctor must cultivate this budding relationship every day in the office during the patient’s active care (and subsequent supportive care phase) with pertinent, unique, and poignant verbal exchange, in order to maximize the patient’s opportunity for care.
In order to prepare for effective doctor patient bonding and communication in the office setting, the doctor must establish protocols for communication in the office. Organizationally, this must involve staff training. This training is best performed by the doctor in order that the staff truly understand the doctor’s personal style, and that the doctor know the capabilities and personal styles of the staff. This creates a unified team approach that is consistent and balanced.5
Information gathering should be conducted in such a way that attention is paid to the patient’s needs, as well as the patient’s desires. Many studies support that patient centered communication is the best approach for gathering pertinent information, in a minimum amount of time,6 while maximizing the doctor patient connection.
An often over-looked component to successful doctor patient communication is the doctor’s personal mental state, focus and preparation for the initial patient encounter. (This positive focus is also important in subsequent encounters such as a report of findings and daily office visits). To be maximally effective, the doctor, regardless the patient schedule or volume, or any other pressing matter, must provide the patient with undivided and uncompromised attention. A suggestion is to gather one’s thoughts, think of the goal of the impending interaction, review the pertinent facts from the patient’s entrance data form and develop a cogent line of inquiry to elucidate the patient’s complaints, and begin to define the patient’s condition. In preparing in this fashion, the doctor is better able to respond dynamically to the patient’s requests or demands. Ironically, from focus and preparation comes dynamic, versatility.
Upon entering the exam room for the first time, the well-prepared doctor is aware of the patient’s primary complaint, and has a general overview of the individual they are about to meet. Is the person employed and if so for whom? Is the individual married or single? What is the patient’s age? Is this person a parent? What is their occupation? Does their occupation contribute to their condition in some way? What are their hobbies? Do they have incidents or conditions in their past history of consequence to your line of questioning? Many doctors have found that matching the patient’s personality style is effective.7 Others have found that mirroring the mannerisms and style of the patient’s body language works well.8 Both approaches are valid depending upon the doctor’s own comfort and skill level. Generally, if the doctor is well prepared intellectually, is confident but not cocky, compassionate, yet focused on problem solving, this patient interaction will be smooth and fruitful. Rhetorical questions posed such as: Mr. Jones, I understand from this form you kindly completed for me, that you are suffering from lower back pain and pain in your right thigh, is that correct? Tell me Mr. Jones; I see here you are a computer programmer. Do you sit most of the day? You noted your pain ranges from a 3-9 out of a possible 10 is that right? Tell me what it feels like when it is at the 9 level. What does it feel like to attempt to work all day at your computer with that kind of pain? Do you feel it is interrupting your concentration significantly yet? When the pain in your thigh is at its worst, how do you feel when you are at work? This type of patient centered questioning provides the opportunity for the patient to respond to the queries posed by the doctor with enough latitude for the patient to voice an opinion or make a statement. Yet, this is in a “doctor structured” fashion so as to maximize the efficiency of the process. Each individual doctor must be fluent enough in his or her own personality and language style to make this communication successful.
Developing a deep understanding of the patient’s condition, and the various specific effects their injury or condition has upon their activities of daily living, is far more valuable than a straight leg test, or for that matter, any combination of orthopedic tests in quantifying and qualifying the nature of the patient’s present illness or condition.9 Understanding in intimate detail the effect the patient’s present illness has upon their ability to sit, stand, bend, attend to their hygienic needs; the status of their sleep habits and even their interpersonal relationship with their spouse is critical and descriptive of the magnitude and impact of the problem or problems.10
The benefits of developing a close professional interpersonal connection with patients has a beneficial effect on many aspects of a patient’s relationship with a doctor and the doctor’s office staff. Patient compliance with a doctor’s recommendations and instructions, scheduling and the willingness of the patient to endure the unique physical challenges posed by CBP® patient protocols is dependent upon the strength and depth of the patient’s connection. Even the sense of value the patient will associate with the care provided is impacted. The peripheral benefit of improved patient retention, potential for maximum structural change, and willingness to pay for what is deemed to be valuable, is far more likely when doctor patient communication is effective. In addition, the likelihood of legal challenges with the doctor’s care is reduced.11
There are many sources available to the clinician wishing to improve communication skills. Reading books and articles, and attending seminars can establish a solid basis for why communication is important. However, to actually improve in one’s ability to communicate, one must practice the art. Studies have demonstrated that role-playing; audio and video review and critique of doctor-patient communications can improve the skill level of a student of communication.12 However, it is evident from the literature that frequent, regular monitoring, of doctor patient, and staff- patient interaction, via audio and video review, provides the best results. Merely attending a seminar alone, regardless the content, will not translate into improved communication skills. The art of communication, specific to chiropractic clinicians, and more particularly, to CBP® doctors, represent a unique skill set. The most effective training system available is through a combination of review of the supportive data, a presentation on the basics of communication, followed by the implementation of audio and video critique in group sessions, and then, subsequent individual sessions reviewed by an experienced clinician and communicator. [The author has extensive, contemporary experience in this approach to improving clinical communication skills with staff, interns and doctors. For more information on learning the art of communication in the context of CBP®, contact the author.]
Doctors must not underestimate the incredible value and power of interpersonal communications with their patients. The power of words and mannerisms, expressions and gestures to engender confidence, promote assurance and develop loyalty in patients must be learned, and implemented, in order to provide the ultimate opportunity for patients to obtain the rehabilitative care they need from CBP® protocols.
REFERENCES
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